The Clinical Utility of Brain SPECT Imaging in Process Addictions

Journal of Psychoactive Drugs, 44 (1), 18–26, 2012Copyright © Taylor & Francis Group, LLCISSN: 0279-1072 print / 2159-9777 onlineDOI: 10.1080/02791072.2012.660101

The Clinical Utility of Brain SPECTImaging in Process Addictions

Daniel G. Amen, M.D.a; Kristen Willeumier, Ph.D.b & Robert Johnson, D.O.c

Abstract — Brain SPECT imaging is a nuclear medicine study that uses isotopes bound toneurospecific pharmaceuticals to evaluate regional cerebral blood flow (rCBF) and indirectly metabolicactivity. With current available technology and knowledge SPECT has the potential to add importantclinical information to benefit patient care in many different areas of a substance abuse practice, includ-ing in the area of process addictions. This article explores the ways brain SPECT has the potential tobe useful to clinicians in helping to understand and direct treatment for complex cases of obesity andsexual addictions. Areas where SPECT can add value include helping clinicians ask better questions,helping them in making more complete diagnoses, evaluating underlying brain systems pathology,decreasing stigma and increasing compliance, and visualizing effectiveness via follow-up evaluations.In particular, SPECT can help in identifying and assessing the issue of brain trauma and toxicity in pro-cess addictions, which may be significant contributing factors in treatment failure. Three illustrativecase histories will be given.

Keywords — brain injuries, brain SPECT, neuroimaging, obesity, process addictions, sexualaddiction, toxicity

Brain SPECT imaging is a nuclear medicine studythat uses isotopes bound to neurospecific pharmaceuticalsto evaluate regional cerebral blood flow (rCBF) and indi-rectly metabolic activity. With current available technologyand knowledge SPECT has the potential to add impor-tant clinical information to benefit patient care in manydifferent areas of an addiction medicine practice, includ-ing in the area of process addictions. This article exploresthe ways in which brain SPECT has the potential to beuseful to clinicians in helping to understand and directtreatment for complex cases of chemical and behavioraladdictions, including sexual compulsivity, overeating, self-harm, purging, gambling, compulsive video-game playing,and compulsive spending/shopping. Four cases studies

aCEO and Medical Director, Amen Clinics, Inc., Newport Beach,CA.

bDirector of Research, Amen Clinics, Inc. Newport Beach, CA.cMedical Director, Sierra Tucson, Tucson, AZ.Please address correspondence to Daniel G. Amen, M.D., Amen

Clinics Inc., 4019 Westerly Place, Suite 100, Newport Beach, CA 92660;email: [email protected]

illustrating the potential usefulness of SPECT in processaddictions will be given.

The American Society of Addiction Medicine’s defi-nition of addiction (ASAM 2011) states there are multipleareas of the brain involved in addiction to food, sex andalcohol and other drugs, such as the frontal cortex, ante-rior cingulate gyrus, nucleus accumbens, amygdala andhippocampus. Yet, even though it is clear that the brainis the organ of behavior, addiction clinicians rarely utilizeavailable brain imaging tools to help with diagnosis andtreatment. Instead, they rely on clinical histories, symp-tom clusters, self-rating questionnaires and mental statusexaminations.

Brain single photon emission computed tomography(SPECT) is in a unique position to be helpful in under-standing the individual pathophysiology of patients suffer-ing from addictions. Areas where SPECT can add valueinclude: helping clinicians ask better questions, makingmore complete diagnoses, evaluating underlying brain sys-tems pathology, decreasing stigma, increasing compliance,and visualizing the effectiveness of treatment via follow-up

Journal of Psychoactive Drugs 18 Volume 44 (1), January – March 2012

Amen, Willeumier & Johnson SPECT Imaging and Process Addictions

scans. Of particular note, SPECT can help identify andassess the issues of brain trauma and toxicity, which may besignificant contributing factors in cases of treatment failure.In this article we will review potential uses of SPECT in anaddiction practice, particularly as it relates to food and sexaddiction.

STANDARD BRAIN SPECT INDICATIONS

SPECT’s prolific use in peer-reviewed research val-idates that it is a well-established and reliable measureof brain function (regional cerebral blood flow, or rCBF).Both the American College of Radiology (ACR 2007)and the European Society of Nuclear Medicine (ESNM)(Kapucu et al. 2009) have published similar evidenced-based medicine (EBM) guidelines for using SPECT inpatient care. The commonly accepted clinical indicationsfor SPECT include:

• Evaluating patients for cerebrovascular disease.• Evaluating patients with suspected dementia includ-

ing early detection, differential diagnosis, and in thepredementia phase, known as mild cognitive impair-ment, SPECT can detect functional deficits and thusguide prognosis.

• Localizing epileptic foci.• Evaluation of traumatic brain injury especially in

the absence of computed tomography (CT) and/ormagnetic resonance imaging (MRI) findings. SPECThas shown perfusion abnormalities in traumatic braininjury despite normal morphology, and results areconsidered to have a prognostic value.

• Evaluation of suspected inflammation to providehelpful information in progressive inflammatory dis-orders including viral encephalitis, vasculitis, andHIV-encephalopathy.

• Assessing brain death.All of these indications, except assessing brain death,are potential contributing factors in addiction medicine.Besides the common indications, the ESNM guidelinesalso state, “SPECT can be useful in other indicationssuch as . . . psychiatric diseases (e.g. for follow-up ofdepression),” which is common in patients with addictivedisorders, including process addictions. Camargo (2001)wrote:

Brain SPECT, in particular, with perfusion agents or with neu-roreceptor imaging radiopharmaceuticals, is rapidly becominga clinical tool in many places. The importance of this tech-nique in nuclear medicine today should not be overlooked,particularly in cerebrovascular diseases, dementias, epilepsy,head injury, malignant brain tumors, movement disorders,obsessive-compulsive disorder, Gilles de la Tourette’s syn-drome, schizophrenia, depression, panic disorder, and drugabuse.

In experienced hands, brain SPECT imaging providesclinically useful information on how an individual’s brain

functions. It allows a more complete diagnostic picture,adding biological information about the presenting prob-lem, and often helps to direct treatment, such as showingthe need to enhance low perfusion areas of the brain or tocalm hyperactive ones.

FIVE WAYS SPECT HAS THE POTENTIAL TO BEHELPFUL IN PROCESS ADDICTIONS

1. SPECT has the Potential to Help Clinicians AskBetter QuestionsHarold Bursztajn, M.D., cofounder of the Psychiatry

and Law Program at Harvard, says that SPECT scans donot give you the answer, they teach you to ask better ques-tions (Bursztajn 2002). The results from a scan do not givea diagnosis per se; they are involved in the investigationof the problem. For example, if a brain injury pattern isseen but not given by history it informs the clinician toask more pointed questions about brain injury, or if a toxicpattern is noticed it guides the clinician to explore furtherfor any possibilities for toxicity. Neuroimaging will nevermap directly over to DSM diagnostic categories, becausethey are based on historical symptom clusters, rather thanon the identification and treatment of specific, dysregulatedneurolophysiologic pathways that have multiple etiologiesand multiple subtypes. That is why there will never be, forexample, a signature SPECT image for depression.

Case 1. B, age 35 and a married firefighter, had failedseveral attempts at treatment for sexual addiction, includingan inpatient treatment program. On the verge of divorce,he was referred for a brain SPECT study to gather moreinformation. Compared to a healthy scan (Figure 1) hisscan showed overall severe low perfusion (Figure 2) ina “diffuse encephalopathic” pattern often seen with someform of toxicity, such as those produced by drugs, alco-hol or an environmental toxin. Several years before, B hadbeen involved in several intense firefights and had experi-enced a smoke inhalation injury. This finding is consistentwith published literature on SPECT and carbon monoxidepoisoning (Choi et al. 1995). Intense brain rehabilitationwas then started as part of B’s treatment program. Thisinformation was helpful to the patient, his wife and hisphysician.

2. SPECT has the Potential to Help Clinicians GiveMore Complete Diagnoses and Not Miss ImportantClinical InformationWithout imaging data clinicians may miss important

pieces of biological information, such as brain injuries,toxic exposure, early dementia vulnerability, and potentialseizure activity. Scans also show if there is hyperfrontality,hypofrontality or significant asymmetries in function.SPECT also helps physicians not miss anatomical lesionsthat may be contributing to the problems. We feel that start-ing with a SPECT scan is more practical than starting with



FIGURE 1Healthy Brain SPECT Study; Surface View

Full, even, symmetrical perfusion. The surface view looks at the top 45% of brain perfusion.

CT scans or MRIs because functional data is also obtained.Here is an example.

Case 2. J, age 43, had been in treatment for sex addic-tion on five different occasions. He had also been diagnosedwith ADHD and mixed personality disorder with narcissis-tic and antisocial features. His treating physician referredhim for a SPECT scan for more diagnostic information.Compared to a healthy SPECT scan, J’s scan (Figure 3)showed low activity in the inferior orbital prefrontal cor-tex, an area of the brain involved with impulse control.In addition, there was asymmetrical low perfusion in theleft superior prefrontal cortex and bilaterally in both tem-poral lobes, more severe on the left side. The low perfusionmore lateralized to the left hemisphere is often seen in atraumatic brain injury pattern. Even though the patient ini-tially denied any history of brain injury, on further detailedquestioning he remembered being knocked unconsciousas a ten-year-old child from being hit in the head witha baseball. The information on the past brain injury plusthe location of the injury helped J understand why he

was having trouble maintaining his sobriety and led tomore specific brain injury treatments, including hyperbaricoxygen therapy, which has been shown to be helpful forrehabilitating brain injuries (Harch et al. 2011).

3. SPECT has the Potential to Help SubtypeAddictions in Individual PatientsThe use of functional neuroimaging in clinical prac-

tice dovetails closely with the spirit of the new ResearchDomain Criteria (RDoC) initiative from the NationalInstitute of Mental Health, which looks to develop newways of classifying psychopathology based on observ-able behavior and neurobiological measures (NIMH 2010).Subtyping illnesses, such as process addictions, based onthe clinical picture plus brain system pathology will beessential to finding appropriate treatments for individualpatients.

Based on the brain SPECT work at the Amen Clinicswe have found that there are different types of anxietyand depression (Amen & Routh 2004), ADHD (Amen



FIGURE 2Patient B with Sex Addiction; Brain SPECT Surface View

Overall low perfusion and scalloping, which is indicative of a pattern of diffuse encephalopathy, in this case likely from toxic exposure.

2002), and addictions (Amen & Smith 2010), includingover-eating disorder. In the case of people who strugglewith food addiction we have seen at least five differentbrain SPECT patterns: compulsive, impulsive, impulsive-compulsive, sad, and anxious (Amen 2011). Giving everyaddict the same treatment plan invites failure and frustra-tion. For example, some addicts struggle with compulsivity,commonly associated with hyperfrontality (Lacerda et al.2003), some struggle with impulsivity, associated with lowprefrontal cortex activity (Goethals et al. 2005), and othersstruggle with both impulsivity and compulsivity. Knowingthe individual brain circuits involved helps clinicians tai-lor the treatment more effectively. Hyperfrontality is morelikely to respond to serotonergic interventions (Diler et al.2004), while hypofrontality is more likely to respond tostimulant medications (Amen, Hanks & Prunella 2008),and patients who are both impulsive and compulsive mayneed both types of intervention. The impulsive-compulsivegroup in our experience is the most common type of addict,

and for weight issues was the group most likely to respondto the fen-fen diet, which was a combination of a sero-tonergic intervention (fenfluramine) and a dopaminergicintervention (phentermine). We postulate that some sad andanxious addicts self-medicate underlying psychiatric dis-orders by their choice of addiction, such as using simplecarbohydrates to raise serotonin levels to help with feelingsof depression or anxiety.

4. SPECT has the Potential to Motivate, DecreaseStigma and Increase ComplianceA SPECT scan helps patients develop a deeper under-

standing of their problems, see their problems from amedical point of view, and dramatically decrease shame,guilt, stigma and self-loathing. Scans also help increaseself-forgiveness, and the forgiveness and understanding ofothers. Patients can see that their problems are, in part,a medical problem and not simply “willfulness run riot.”SPECT scans are also powerful for families, and help to



FIGURE 3Patient J with Sex Addiction; Brain SPECT Surface View

Low perfusion noted in inferior orbital prefrontal cortex, left superior prefrontal cortex and both temporal lobes, more severe on the left.

mobilize them in a similar way as when medical illnesses,such as cancer or heart disease, are present. There is noth-ing else in psychiatry that results in such an immediate andstrong intervention to decrease stigma.

A SPECT scan helps to increase compliance—picturesare powerful. These are very powerful influences in deter-mining a patient’s willingness and ability to accept andadhere to a treatment program, as they realize that nottaking care of their brain or treating underlying illnessesis similar to not wearing the right prescription for theireyes.

Case 3. F, a 57-year old self-employed businessmanwho was married for the third time, was admitted to thehospital for depression, substance abuse, PTSD, and sex-ual compulsivity. The admission was initially triggered byhis wife’s request for a divorce after he and his wife wereserved with child support papers in their driveway as theywere about to leave for a vacation, related to a six-year-old

son from a prior affair that the patient had not divulged tohis wife.

On admission the patient stated, “I am a failed manwithin my family. I love my wife. I just don’t know what’swrong with me . . . how come I continue to engage inthis behavior?” A prior psychiatric hospitalization for sexaddiction, regular church involvement, and ongoing immer-sion in a 12-Step program had not enabled him to maintainsexual sobriety.

F had a past history of cocaine abuse and a bipolarType II mood cycling pattern consisting of hypomania anddepression, in addition to atypical four-day cycles of milddepression that triggered escalating levels of anxiety/panic,vomiting, psychosocial withdrawal/isolation, and dissoci-ation. These latter cycles began four years prior, a weekafter his current wife left him for the first time in responseto the discovery of an adulterous affair, and a day afterhe discovered an employee who had been murdered in his



FIGURE 4Patient F with Brain Trauma, ADHD and Toxic Exposure; Brain SPECT Surface View

Decreased activity in the left and right parietal, occipital, and temporal lobes (consistent with a past brain trauma), decreased left and right inferiororbital prefrontal cortex activity (consistent with ADHD), and moderate scalloping (consistent with past substance abuse). The low prefrontal cortexactivity is often associated with a broken “brake,” leaving trouble with impulse control. The low temporal lobe activity is often associated with moodinstability.

office. This cycle of PTSD-related emotional activation,autonomic reactivity, and dissociation would also recurafter each bout of sex outside of his marriage, which mostoften occurred during periods of hypomania. This patientalso had a history of “mild” sports-related traumatic braininjuries and ADHD.

As part of a comprehensive assessment a brain SPECTstudy was performed (Figure 4), which showed decreasedactivity in the left and right parietal, occipital, and temporallobes (consistent with past brain trauma), decreased left andright inferior orbital prefrontal cortex activity (consistentwith ADHD, brain trauma, and/or substance abuse), andmoderate scalloping (consistent with past cocaine abuse).The low temporal lobe activity is often associated withmood instability. A primary role of the prefrontal cor-tex is to enable intention to guide behavior; as a result,

low prefrontal cortex activity is often reflective of a bro-ken frontal lobe “brake” or “filter,” resulting in persistentstruggles with impulse control, even in highly motivatedindividuals.

Putting these SPECT findings and the patient’s clini-cal history together, the combination of hypomanic cyclingwith a broken frontal lobe filter from traumatic braininjuries, ADHD, and toxicity from prior cocaine abuse cre-ates a perfect recipe for the perpetuation of a very vexingand persistent process addiction.

The scan images were very helpful for the patient andhis wife; during his SPECT feedback session, the patientbegan to weep, and stated, “I can’t tell you how pow-erful this is for me . . . as strange as it sounds, it’s arelief to see that at least a part of this is related to howmy brain functions. I know it’s not a get-out-of-jail-free



FIGURE 5Patient A—Before Image; Brain SPECT Surface View

Low overall perfusion

card, but I’ve never understood how I’ve been able to besuccessful in so many other areas of my life, but havenot been able to control this addiction, or my responseto traumatic events—even the trauma of betraying myown core values.” This realization helped to shift thedialogue from willfulness, lack of self-discipline, andshame to the physiologic effects on the brain of phys-ical and psychological trauma, ADHD, and substanceabuse.

5. SPECT has the Potential to Visualize HowEffective Treatments are Working ThroughFollow-Up ScansFollow-up scans can provide evidence of a treatment’s

effectiveness or ineffectiveness for both clinicians andpatients. Once a plastic surgeon does a procedure he andthe patient can visualize the outcome and see a positiveor negative effect of the work. SPECT provides a similar

opportunity. Follow-up scans also make clinicians moreresponsible. When a follow-up scan shows the patient’sbrain is worse, rather than blame the patient, clinicians canredesign the plan.

Case 4. A, a 53-year-old male, was concerned aboutbrain health and came for an evaluation, including brainSPECT. His scan showed severe overall low activity(Figure 5). He admitted to drinking three to four alcoholicdrinks a day, but reported he was never drunk and it didnot cause any problems for him. He was also 100 poundsoverweight. When A saw his scan and learned that as a per-son’s weight goes up, the actual size and function of thebrain goes down (Willeumier et al. 2011; Raji et al. 2010),it motivated him to get healthy. He stopped drinking alco-hol and lost 100 pounds. Eleven years later he came backfor a follow-up SPECT scan to see his progress, which wasdramatic, both in terms of his brain health (Figure 6) andoverall physical health.



FIGURE 6Patient A—After Image; Brain SPECT Surface View

Marked overall increase in perfusion

CONCLUSION

There is a converging body of literature and clinicalexperience on the usefulness of brain SPECT imaging ina number of areas relevant to addiction medicine. Someauthors have written that it is unethical to order scans whenthere is not yet enough consensus or research on the clin-ical use of imaging (Bush 2008). We believe that it is not

only unethical to withhold potentially valuable informationfrom clinicians, patients and families, it also hurts the medi-cal profession and society at large. Still, there is much workto do to bring widespread use of brain imaging into clini-cal practice for substance abuse practitioners. The next twodecades will see a radical shift in the way substance abusetreatment and psychiatry is practiced, and imaging will playan important role in the change.

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The Clinical Utility of Brain SPECT Imaging in Process Addictions

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